Chapter 11: Providing Patient-Centered Care Through the Nursing Process My Nursing Test Banks

Chapter 11: Providing Patient-Centered Care Through the Nursing Process

Test Bank

MULTIPLE CHOICE

1. Which statement by the nurse illustrates how a nursing patient assessment differs from a medical patient assessment?

a.

The patient is able to stand for 30 seconds before walking 10 feet toward the bathroom without an assistive device.

b.

The patient is fearful that he will not be discharged home after his hospitalization.

c.

The patient stated he felt pain in his lower back after slipping on his icy driveway.

d.

The patient experienced a persistent cough, and azithromycin was prescribed 6 weeks ago. Today, she presents with a recurrent cough, green sputum, and worsening shortness of breath.

ANS: A

The patients being able to stand and walk is the correct answer. The nurse focuses on functional abilities and deficits in order to focus the plan of care and help identify the outcome priorities. These areas are not generally assessed by the physician. The patients feeling fearful of his disposition at discharge is incorrect because the nursing patient assessment does not focus on feelings and behavior. In addition to subjective data illustrated here by the patients stating the location of his pain, the nurse also uses objective data for the nursing patient assessment. The statement describing the patients medical history is not the focus of a nursing patient assessment.

DIF: Cognitive Level: Evaluation REF: Page 164

OBJ: Differentiate between the nursing patient assessment and the medical patient assessment.

TOP: Nursing Process

MSC: NCLEX: Safe, Effective Care Environment: Management of Care

2. The nurse is using Gordons 11 categories for data collection in performing a health assessment. Which of the following represents assessment of cognition?

a.

How educated is the patient?

b.

How does the patient describe his or her health?

c.

Is the patient well nourished?

d.

Has the patient had treatment for emotional problems?

ANS: A

Asking the patients educational level is an assessment of cognition. How the patient describes his or her health is an assessment of health perception and health management. Asking whether the patient is well nourished will assess metabolic pattern, and asking the patient about treatment for emotional problems will assess the patients pattern of coping and stress tolerance.

DIF: Cognitive Level: Application REF: Page 165

OBJ: Discuss the five realms that may affect a patients health status that should be addressed in order to complete a thorough nursing assessment. TOP: Nursing Process

MSC: NCLEX: Psychosocial Integrity

3. The nurse is charting on the patient who is status post surgery for an abdominal abscess and notes: Pts temperature has not exceeded 37C this shift. This is an example of a(n):

a.

intervention.

b.

outcome.

c.

plan.

d.

diagnosis or analysis.

ANS: B

An outcome measures the effectiveness of the plan of care. An intervention, a plan, and a diagnosis or analysis are incorrect.

DIF: Cognitive Level: Analysis REF: Page 168

OBJ: Compare and contrast the nursing tasks in each phase of the nursing process.

TOP: Nursing Process

MSC: NCLEX: Safe, Effective Care Environment: Management of Care

4. Which outcome statement is a properly written goal?

a.

The patient will be free of pain.

b.

The patient will verbalize the importance of lifestyle changes.

c.

The patient will get up into the chair one time daily for 1 hour.

d.

The patient will demonstrate breathing techniques by the end of shift.

ANS: C

To be evaluated, an expected outcome must be specific and measurable, meaning that the outcomes can be consistently evaluated. The patient will get up into the chair one time daily for 1 hour is specific and measurable. The other outcome statements are vague and open to interpretation. First, being free from pain may mean absolutely no pain or a tolerable level of pain. Second, identifying which lifestyle changes are important to teach the patient may differ from nurse to nurse. Finally, there may be several breathing techniques to teach the patient.

DIF: Cognitive Level: Evaluation REF: Page 168

OBJ: Explain the steps of the nursing process. TOP: Nursing Process

MSC: NCLEX: Safe, Effective Care Environment: Management of Care

5. The nurse is planning care for a patient with hypertension and obesity. Which of the following is a reasonable and measurable outcome for the nursing diagnosis of noncompliance with treatment regimen related to side effects of medications?

a.

The patient will state two lifestyle modifications for weight management by (date certain).

b.

The patient will be compliant with the treatment regimen by (date certain).

c.

The patient will understand the disease process by (date certain).

d.

The patients blood pressure will never increase.

ANS: A

The patients stating two lifestyle modifications for weight management is reasonable and measurable. The patients being compliant with the treatment regimen is vague. The patients understanding the disease process does not state how the effectiveness of teaching will be measured (e.g., by return demonstration or verbalization). The patients blood pressure not increasing is not reasonable.

DIF: Cognitive Level: Application REF: Page 168

OBJ: Formulate and apply reasonable and measurable outcomes to the practice setting.

TOP: Nursing Process

MSC: NCLEX: Safe, Effective Care Environment: Management of Care

6. A patient admitted with a diagnosis of Alzheimers disease is anxious and dehydrated, has reportedly not been eating, and has had a weight loss of 5 lb in 1 week. Which nursing diagnosis is a priority?

a.

Fluid volume deficit related to fluid loss

b.

Altered nutrition: Less than body requirements related to anorexia

c.

Fluid volume excess related to reduced urine output

d.

Risk for impaired skin integrity

ANS: A

Replacing fluids is the priority. Anorexia is common in the elderly and can be related to many conditions, including dementia. Fluid volume excess is not present. Risk for impaired skin integrity is not the priority.

DIF: Cognitive Level: Analysis REF: Page 167

OBJ: Formulate an actual, potential, and wellness nursing diagnosis.

TOP: Nursing Process

MSC: NCLEX: Safe, Effective Care Environment: Management of Care

7. An RN team leader has one LPN and one medical assistant assigned to the unit. Which patient would be most appropriate to assign to the LPN?

a.

Right lower lobectomy, one day postoperatively, whose temperature went from 37.1C to 38.3C during the last shift

b.

72-year-old right hip replacement, 2 days postoperatively, complaining of leg and chest pain

c.

48-year-old female patient who had a laparoscopic appendectomy 8 hours ago: urine output 165 mL, Hgb 7 g/dL, and Hct 21%

d.

Post cerebral vascular accident 1 week ago who had a Dobhoff feeding tube inserted and is now on continuous feedings at 45 mL/hr

ANS: D

Licensed practical nurses can implement actions specific to the patient care needs. Monitoring the stroke patient and maintaining the continuous feeding is an appropriate delegation. LPNs can also collect data, perform basic teaching, record data as well as interventions, and report to the RNs the progress the patient is making. The patient one-day post-op from the right lower lobectomy, the patient with the hip replacement, and the patient with the appendectomy are inappropriate to delegate to a LPN because each requires a focused assessment, advanced interventions, evaluation, and updating of the patients plans of care and outcome priorities.

DIF: Cognitive Level: Application REF: Page 171

OBJ: Explain the steps of the nursing process. TOP: Nursing Process

MSC: NCLEX: Safe, Effective Care Environment: Management of Care

8. Which of these strategies should be a priority when the nurse is planning care for a patient with hypertension?

a.

Obtain less expensive antihypertensive medications.

b.

Assist with dietary changes as the first action.

c.

Follow evidence-based guidelines for appropriate interventions.

d.

Teach about the impact of exercise on hypertension.

ANS: C

Planning goals and desired outcomes occurs in the planning phase. The plan of care includes the process of identifying the interventions needed for the patient to regain a level of independence at or higher than the patient had before admission into the hospital.

DIF: Cognitive Level: Application REF: Page 169

OBJ: Explain the steps of the nursing process. TOP: Nursing Process

MSC: NCLEX: Safe, Effective Care Environment: Management of Care

9. The nurse reviews assessment findings for assigned patients. Based on this information, which patient demands the nurses immediate attention? The patient with:

a.

renal failure on dialysis whose WBC is 10,000 mm3 (normal)

b.

abdominal aneurysm whose blood pressure is 170/90

c.

atrial fibrillation whose lab results show and INR of 2.5 (normal)

d.

endocarditis who has a loud heart murmur

ANS: B

Assessment contains both objective and subjective data. Among other things, the nurse interprets laboratory data to determine whom to see first. The hypertensive patient with an abdominal aneurysm presents the greatest emergency. The patient on dialysis, the patient with A-Fib, and the patient with endocarditis all have normal lab values and clinical findings and present no urgent need for attention.

DIF: Cognitive Level: Application REF: Page 163

OBJ: Explain the steps of the nursing process. TOP: Nursing Process

MSC: NCLEX: Safe, Effective Care Environment: Management of Care

10. While the nurse is taking the health history, the patient states, My father and grandfather both had heart attacks and were unable to be very active afterward. This statement is related to the functional health pattern of:

a.

activity-exercise.

b.

cognitive-perceptual.

c.

health perceptionhealth management.

d.

coping-stress tolerance.

ANS: C

The information in the patients statement relates to risk factors that may cause cardiovascular problems in the future. Identification of risk factors falls into the health perceptionhealth management pattern. This pattern describes a patients perceived pattern of health and how health is managed.

DIF: Cognitive Level: Knowledge REF: Page 164

OBJ: Explain the steps of the nursing process. TOP: Nursing Process

MSC: NCLEX: Safe, Effective Care Environment: Management of Care

11. Which of the following is an example of a measurable outcome for the patient who has undergone a surgical procedure with a pain rating of 7 on a scale of 0 to 10?

a.

The patients pain will be under control by Sunday.

b.

The patient will have no pain by the end of this shift.

c.

The patients pain will decrease by the end of shift on (date).

d.

The patients pain will decrease to 2 or lower by the end of shift on (date).

ANS: D

The patients pain will decrease to 2 or lower by the end of shift on (date) states what is to be measured, how much it will decrease, and by when. The patients pain will be under control by Sunday, The patient will have no pain by the end of this shift, and The patients pain will decrease by the end of shift on (date) do not include these elements.

DIF: Cognitive Level: Application REF: Page 168

OBJ: Formulate and apply reasonable and measurable outcomes to the practice setting.

TOP: Nursing Process

MSC: NCLEX: Safe, Effective Care Environment: Management of Care

12. Which of the following would be a priority nursing diagnosis for a 73-year-old male patient with heart failure?

a.

Constipation related to immobility

b.

Risk for infection related to IV lines

c.

Activity intolerance related to an imbalance of oxygen and demand

d.

Self-care deficit

ANS: C

Remember your ABCs. The highest priority for this patient is to conserve energy. Constipation related to immobility, risk for infection related to IV lines, and self-care deficit are not priorities.

DIF: Cognitive Level: Analysis REF: Page 166

OBJ: Examine and prioritize nursing diagnoses in the practice setting.

TOP: Nursing Process

MSC: NCLEX: Safe, Effective Care Environment: Management of Care

13. Which of the following would be an expected outcome for a patient who is 12 hours status post hip replacement?

a.

Increase mobility and decrease pain.

b.

Care for the catheter independently.

c.

Walk without assistance.

d.

Bathe daily in a tub.

ANS: A

A reasonable outcome is that the patients mobility will increase as pain decreases. Care for the catheter independently is incorrect because the patient would not be expected to have a catheter. Walking without assistance and bathe daily in a tub are not reasonable for the patient 12 hours status post hip replacement.

DIF: Cognitive Level: Analysis REF: Page 168

OBJ: Formulate and apply reasonable and measurable outcomes to the practice setting.

TOP: Nursing Process

MSC: NCLEX: Safe, Effective Care Environment: Management of Care

14. An RN is making assignments on a medical-surgical unit. Which patient could the RN assign to a float RN from the maternity unit?

a.

A 68-year-old female patient with COPD and viral pneumonia

b.

A 60-year-old female patient with atrial fibrillation and a heart rate of 150

c.

A 50year-old male patient post open heart surgery whose blood pressure is 90/50

d.

A 36-year-old male patient who is severely neutropenic awaiting chemotherapy

ANS: A

When prioritizing nursing care, the most critical problems receive the highest priority. In this scenario, the float nurse from another department serves as another health care team member unfamiliar with the medical-surgical patient population. The medical-surgical RN serves as an all-around organizer of care and interventions that other health care team members provide. The patient with COPD and viral pneumonia is the most stable of the group. The patient with A-Fib, the post open heart surgery patient with dangerously low blood pressure, and the neutropenic patient awaiting chemotherapy all require close attention and advanced interventions by the RN familiar with these types of patients.

DIF: Cognitive Level: Application REF: Pages 167, 171

OBJ: Explain the steps of the nursing process. TOP: Nursing Process

MSC: NCLEX: Safe, Effective Care Environment: Management of Care

15. A patient with pneumonia has been using the incentive spirometer four times daily while awake during his 3-day hospitalization. How would the nurse explore the effectiveness of this intervention?

a.

The nurse would ask whether the patient was breathing better.

b.

The nurse would add turn, cough, and deep breathing exercises.

c.

The nurse would watch the patient use the incentive spirometer.

d.

The nurse would auscultate the lungs for adventitious breath sounds.

ANS: D

The nurse would evaluate the effectiveness of the incentive spirometer treatment by listening for adventitious lung sounds. Asking whether the patient is breathing better; adding turn, cough, and deep breathing exercises; and watching the patient using the incentive spirometer do not examine the effectiveness of the plan of care.

DIF: Cognitive Level: Synthesis REF: Page 171

OBJ: Explain the steps of the nursing process. TOP: Nursing Process

MSC: NCLEX: Safe, Effective Care Environment: Management of Care

16. Which nursing diagnosis would be a priority for a patient in acute respiratory distress?

a.

Pain

b.

Impaired gas exchange

c.

Activity intolerance

d.

Deficient knowledge

ANS: B

Remember your ABCs. Airway is always a priority. Pain, activity intolerance, and deficient knowledge are not priorities.

DIF: Cognitive Level: Analysis REF: Page 167

OBJ: Examine and prioritize nursing diagnoses in the practice setting.

TOP: Nursing Process

MSC: NCLEX: Safe, Effective Care Environment: Management of Care

17. Determine which example is true of measurability within the context of the nursing diagnosis.

a.

The patient will list signs of infection such as redness, pain, swelling, and warmth by the end of the shift.

b.

The patient will be pain-free and then walk to the bathroom.

c.

The patient reported abdominal pain for 2 days but denies nausea, vomiting, and diarrhea.

d.

The patient received Dilaudid 1 mg IV and 2 hours later received Lortab 500/5.

ANS: A

Measurability provides the means to evaluate outcomes consistently. The outcome criterion of listing the specific signs of infection is consistently measurable by anyone choosing to attain that outcome criterion. Being pain-free and then walking to the bathroom is not measurable because one outcome criterion cannot depend on completion of another criterion. Each outcome criterion is considered an individual goal. The statements addressing abdominal pain and nausea, vomiting, diarrhea are collected data and taking account of the pain medications administered to the patient have nothing in common with measurability.

DIF: Cognitive Level: Evaluation REF: Page 168

OBJ: Explain the steps of the nursing process. TOP: Nursing Process

MSC: NCLEX: Safe, Effective Care Environment: Management of Care

18. The nurse is admitting a 64-year-old Hispanic male patient to the rehabilitation facility following surgical intervention for a broken hip. The nurse should first assess which of the following?

a.

Self-care ability

b.

Self-esteem

c.

Communication

d.

Pain

ANS: D

Pain is the first priority for the patient admitted for rehabilitation following surgical intervention. Self-care ability and self-esteem are not the first to be assessed. The ability to communicate pain can be facilitated using graphic representations if the patient does not speak English.

DIF: Cognitive Level: Analysis REF: Page 167

OBJ: Examine and prioritize nursing diagnoses in the practice setting.

TOP: Nursing Process

MSC: NCLEX: Safe, Effective Care Environment: Management of Care

19. The nurse is attempting to take the history of a newly admitted 92-year-old patient but is unable to obtain the information because of the patients cognitive status. The nurse should:

a.

refuse to complete the admission without more information.

b.

contact the family for information on the patients history.

c.

call the doctor in the emergency room for a history.

d.

ask another nurse to try to obtain the information from the patient.

ANS: B

The nurse should contact the family to obtain the needed information. Refusing to complete the admission without more information is not professional. Calling the doctor in the emergency room for a history is not likely to be helpful, and asking another nurse to try to obtain the information from the patient is not likely to change the outcome because of the patients cognitive status.

DIF: Cognitive Level: Analysis REF: Page 164

OBJ: Explain the steps of the nursing process. TOP: Nursing Process

MSC: NCLEX: Safe, Effective Care Environment: Management of Care

20. The nurse is planning care for an 82-year-old obese female patient with Alzheimers dementia. The patient wanders, is unsteady on her feet, and is visually impaired. What should the nurse give priority to when developing the plan of care?

a.

Laboratory results

b.

Skin condition

c.

Safety

d.

Nutrition

ANS: C

Safety is the first priority for this patient who is cognitively and visually impaired, wanders, and is unsteady. Laboratory results should be monitored, but safety is the priority. Skin condition and nutrition are of concern but are not immediate priorities.

DIF: Cognitive Level: Analysis REF: Page 167

OBJ: Examine and prioritize nursing diagnoses in the practice setting.

TOP: Nursing Process

MSC: NCLEX: Safe, Effective Care Environment: Management of Care

21. Which of the following is true about collaborative problems?

a.

Collaborative problems fall within the definition of nursing diagnoses.

b.

Collaborative problems are managed using two physicians.

c.

Collaborative problems require the nurse to monitor for changes in status.

d.

Collaborative problems emphasize prevention, treatment, or health promotion.

ANS: C

Collaborative problems require the nurse to monitor for changes in patient status and for the onset of complications for specific situations. Collaborative problems do not fall within the definition of nursing diagnoses. The statement that collaborative problems are managed using two physicians is not true, and the statement that collaborative problems emphasize prevention, treatment, or health promotion is true of the nursing diagnosis phase of the nursing process.

DIF: Cognitive Level: Knowledge REF: Page 170

OBJ: Explain collaborative problems with respect to formulating the nursing diagnosis in the practice setting. TOP: Nursing Process

MSC: NCLEX: Safe, Effective Care Environment: Management of Care

22. Errors may occur with the use of data in formulating an appropriate nursing diagnosis. Based on what you know, which of the following represents the main source of errors in the nursing diagnosis process?

a.

Making assumptions without supporting data

b.

Placing data in incorrect categories

c.

Not validating data with the patient

d.

Relying on team members for data

ANS: A

Every nursing diagnosis must be substantiated by identifying criteria, also known as defining characteristics. For a nursing diagnosis to be accepted, often numerous signs and symptoms together make up the actual diagnosis. These identifying criteria must be present in the patient to assign that diagnosis. Placing data in incorrect categories, not validating data with the patient, and relying on team members are not discussed.

DIF: Cognitive Level: Evaluation REF: Page 166

OBJ: Explain the steps of the nursing process. TOP: Nursing Process

MSC: NCLEX: Safe, Effective Care Environment: Management of Care

23. An example of an intervention independently initiated by the nurse is:

a.

starting a teaching plan for the patient who will go home tomorrow.

b.

instituting diet restrictions with subsequent progression of diet as tolerated.

c.

sending an abnormal appearing urine sample to the lab for routine urinalysis.

d.

writing an order for aspirin for a headache.

ANS: A

Starting a teaching plan is an independent nursing function. Accountability for both independent and interdependent functions remains a part of the role of the RN. Instituting diet restrictions, sending a sample for urinalysis, and writing an order are not functions of a nurse and require physicians orders to carry out.

DIF: Cognitive Level: Application REF: Page 171

OBJ: Explain the steps of the nursing process. TOP: Nursing Process

MSC: NCLEX: Safe, Effective Care Environment: Management of Care

24. A nursing intervention directs the patient to be turned every 2 hours to prevent skin breakdown from immobility. Assessment findings on new reddened areas on the lateral aspects of the right knee and ankle are obtained. What is the most appropriate way for these findings to be used when the care plan is evaluated?

a.

The information will be added to the relevant area of the electronic medical record.

b.

The nursing diagnosis will be changed from an actual problem to a potential problem.

c.

The new intervention of calling the physician will be added to the care plan.

d.

The intervention will change to have the patient turned every hour.

ANS: D

Evaluation is the process of examining the effectiveness of the plan of care and adjusting it to ultimately meet the needs of the patient. Because redness is observed over bony prominences with turning the patient every 2 hours, the intervention must be adjusted, so the patient must be turned more frequently to prevent further skin breakdown. Documenting of information in the electronic medical record does not address the immediate skin integrity problem. Changing the actual problem to a potential problem is incorrect. Calling the physician is not an independent nursing intervention and does not address the issue of skin integrity.

DIF: Cognitive Level: Application REF: Page 171

OBJ: Explain the steps of the nursing process. TOP: Nursing Process

MSC: NCLEX: Safe, Effective Care Environment: Management of Care

MULTIPLE RESPONSE

1. In the assessment phase of the nursing process, there are several ways to collect data. Which statements reflect the need for more training? (Select all that apply.)

a.

The patient is talking in full sentences with visitors and appears to be breathing without distress.

b.

Bowel sounds are hypoactive in all four quadrants; no pain with palpation.

c.

Mrs. Collins, are you experiencing any pain right now?

d.

According to the chart, the patient slept well last night as a result of the pain medicine administered at 2100.

e.

The abdominal wound is slightly red at the approximated edges, no edema noted.

ANS: C, D

Methods of data collection include observation, physical assessment, and interviewing. Asking yes-no questions may limit the information received. Reading the chart for any previous notes is important to know for continuity of care, but it is not a method of data collection in the assessment phase of the nursing process. Noticing the patient speaking in full sentences tells the nurse the patient is in no distress. Auscultating and palpating the abdomen are part of the physical assessment done at the beginning of every shift and as needed. Noting wound healing including redness and edema is a direct observation.

DIF: Cognitive Level: Application REF: Page 164

OBJ: Explain the steps of the nursing process. TOP: Nursing Process

MSC: NCLEX: Safe, Effective Care Environment: Management of Care

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